Provider Demographics
NPI:1811176894
Name:PRO SPORTS & SPINE REHABILITATION, SC
Entity type:Organization
Organization Name:PRO SPORTS & SPINE REHABILITATION, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SARANTOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:630-924-1450
Mailing Address - Street 1:6374 N LINCOLN AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1275
Mailing Address - Country:US
Mailing Address - Phone:630-924-1450
Mailing Address - Fax:630-924-1459
Practice Address - Street 1:6374 N LINCOLN AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1275
Practice Address - Country:US
Practice Address - Phone:630-924-1450
Practice Address - Fax:630-924-1459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094371208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01638376OtherBLUE CROSS BLUE SHIELD